Susan Dentzer
editor-in-chief of Health Affairs, and an on-air analyst on health issues for The PBS NewsHour

Ceci Connolly
managing director and leader of PwC's Health Research Institute; co-author of "Landmark: The Inside Story of America's New Health Care Law and What It Means for Us All."

Transcript

10:06:56

MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Now that it's clear the Affordable Care Act will be with us at least for the foreseeable future, many people are scrambling to figure out just what changes and what does not change for them. Joining me in the studio to answer your questions: Julie Rovner of NPR, Susan Dentzer of Health Affairs and the PBS "NewsHour," Mary Agnes Carey of Kaiser Health News, and Ceci Connolly of PwC Health Research Institute.

10:07:33

MS. DIANE REHMI know there's been a lot of confusion and questions, so feel free to call us with your own. You can join us on 800-433-8850. Send us your email to drshow@wamu.org. Join us on Facebook or Twitter. And thanks to all of you for being here this morning. Good to see you.

10:08:00

MS. CECI CONNOLLYGreat to see you, Diane.

10:08:00

MS. JULIE ROVNERGood morning, Diane.

10:08:00

MS. SUSAN DENTZERGood morning.

10:08:01

MS. MARY AGNES CAREYGreat to be here.

10:08:02

REHMAnd let's start with you, Julie Rovner. There are certain pieces of this health care act that are currently in place. Tell us what they are and how they will affect people this year and next.

10:08:20

ROVNERWell, there are actually lots of pieces of this health care act that are in place even though what mostly people have been arguing about are the pieces that haven't taken effect yet, particularly this individual mandate. There are 3.6 million seniors who are already saving about $2.1 billion on their medications, thanks to the gradual closing of this doughnut hole in prescription drug coverage. That's happening over about 10 years.

10:08:46

ROVNERThere will no more -- there will no longer be a gap where seniors pay their premiums and do not get coverage for their prescription drugs. There are now 3.1 million young adults who are remaining on their parents' health plans up to their 26th birthday. That's something that this law provided. There are somewhere around 13 million people, policyholders, who will be getting rebate checks from their insurance companies between now and August 1 because insurance companies are no longer allowed to keep more than 80 cents on a dollar that they spend.

10:09:23

ROVNERThey must spend no more than 80 cents -- they must spend at least 80 cents on a dollar on actual medical claims and not on administration and overhead. Sorry, it's kind of hard to say. So those are some of the things. There are a lot of new protections for people in the health insurance market in terms of what insurance companies can do in terms of lifetime limits, annual limits, how much care they have to provide.

10:09:52

ROVNERA lot of new preventive health care benefits that are available so that there are -- small businesses have available tax credits, very small businesses under 25 have available tax credits. There's about $5 billion for early retiree coverage that went -- that's all been spent already that went out to businesses who wanted to keep them from dropping that coverage. And there are these high-risk pools for people with pre-existing conditions. They have not been taken advantage of very much, but those are there to tie people over until 2014. That's just -- that's some of it. There's even more.

10:10:28

REHMAnd, Ceci, according to this plan, by 2014, how many Americans will be covered?

10:10:37

CONNOLLYWell, the initial projections, Diane, were that the Affordable Care Act would bring 33 million additional Americans into the health insurance pool. Now that number is likely to come down a little bit because of the one twist that came out of the Supreme Court last week. As you recall, the court decided that the expansion of the Medicaid program to up to 133 percent of the poverty level -- and that's about $35,900 for a family of four.

10:11:14

CONNOLLYThe Supreme Court indicated that that expansion would be essentially optional for states. States would not be penalized if they decided not to go up to that level. So as a result, everyone, including, most importantly, the Congressional Budget Office, now needs to look a little bit at those original projections. It probably means that that 33 million comes down by a few million depending on what the states decide to do.

10:11:40

REHMAnd, Susan Dentzer, Julie talked about the Medicare folks and the doughnut hole. How many of those Medicare -- people currently on Medicare are going to receive additional benefits?

10:12:02

DENTZERWell, all Medicare beneficiaries now are covered by the preventive services provisions that Julie mentioned so that, for example, if you're on Medicare or you're going on Medicare today, colonoscopies will be covered with no cost sharing, mammograms will be covered with no cost sharing. That means no co-payments, no deductibles, et cetera.

10:12:22

DENTZERAll the services that get a top rating from a federal government task force that's appointed to look at all of the preventive services and see the evidence that things are really working and are cost effective, all of those services will now be covered for all Medicare beneficiaries.

10:12:39

REHMAnd, Mary Agnes Carey, who is going to be shut out of this plan going forward to 2014?

10:12:49

CAREYWell, Ceci mentioned the Medicaid expansion is optional for governors. So if a governor decides not to expand the Medicaid program, then individuals in those states, from 100 percent poverty and higher, they could try -- they could go for a subsidy, but they wouldn't get -- they're going to have to pay some money out of their pockets, will cost them more. But if they're under 100 percent of the poverty level, they're not going to have any help. They won't have any help on this -- in this law if the governor turns down the expansion.

10:13:17

REHMSo what is the governor's interest in turning down the expansion, Ceci?

10:13:25

CONNOLLYWell, it's a great question, Diane, because in essence, for the first few years, for the first three years that this law will take place, 2014 to 2017, it is free money for the states. They're -- the federal government, it states in the law, will pick up 100 percent of the cost of any of those individuals who come on to Medicaid because of the expansion. Then for the next three years, the federal government will pay 95 percent of the cost. And then beginning in 2020, it's 90 percent. So there is a gradual tapering off.

10:14:06

CONNOLLYBut contrast to that with today, the average amount of money that the federal government contributes to Medicaid is 57 percent. So this is a good deal for states, but it would not be free forever. And the concern that some governors are now articulating is that it could change and it could come down lower in the future and then they would be responsible for that portion whether it's the 5 percent or the 10 percent.

10:14:34

REHMBut, Susan Dentzer, have you ever known governors to turn down free money?

10:14:40

DENTZERIt is not been common, and let's point out that all the states have been essentially taking federal funding to support their Medicaid programs for quite some time. And also, a number of these states have a lot of uninsured people who would fit into these categories. So they will face the decision about whether it's better to say to pockets of people, sorry, we're not going to take this money, or decide that, in fact, they have an interest in covering those citizens.

10:15:10

DENTZERI will say the states do point out that they will have to carry administrative costs of the program over time, and that will -- so it won't be entirely free for them. And they're -- there are some arguments about some other aspects of the program that the -- some of the states feel also will cost them more. Right now, there are lots of dueling cost estimates going around, you know, some states looking at estimates that show just extremely large sums of money that they may have to pay.

10:15:35

DENTZEROthers pointing out that those are really unrealistic and make -- or and also represent unfair interpretations of what's actually in the law. So we're going to hear a lot of this back and forth over the next few months and probably beyond that till people sort out what really is going to be the policy in individual states.

10:15:53

REHMAll right. I want to take as many calls as possible during this hour. Let's start with Bill in Chesapeake, Va. Good morning to you, sir.

10:16:05

BILLGood morning. Thank you for taking my call.

10:16:07

REHMSurely.

10:16:08

BILLMy wife and I have a 45-year-old son who has Asperger's syndrome and epilepsy controlled by medication. He works for a 30-hour-a-week job at a plant nursery, and, of course, he doesn't have health insurance. So my question is, what will the Affordable Health Care Act be able to offer him given the fact that in Virginia, our governor, has -- and the attorney general has fought tooth and nail and probably will not implement the Medicaid expansion?

10:16:36

REHMCeci.

10:16:37

CONNOLLYWell, Bill, without knowing the precise amount of his income but the way that you describe his job in 30 hours a week, it sounds to me as if he would be eligible for those subsidies to purchase health insurance on the state exchange. Enrollment in those exchanges is scheduled to begin in fall 2013. The coverage would kick in January 2014. And again, as Mary Agnes mentioned, subsidies are going to be available on kind of a sliding scale basis from 100 percent of poverty up to 400 percent of poverty.

10:17:12

CONNOLLYIt does sound that he would very much fall within that range, and so it's essentially discounted health insurance for him. Importantly, I think we should point out that right now, people like Bill's son can be turned down by the insurance companies because of an existing condition, and that will also change under the Affordable Care Act. Those individuals will not be able to be denied coverage. The pre-existing exclusion for children has already kicked in.

10:17:42

REHMJulie, do you want to add to that?

10:17:44

ROVNERYes. The only thing I would add to that -- and this is building on something that Mary Agnes said -- if governors choose not to take this Medicaid expansion, there's going to be a gap for people who earn less than 100 percent of poverty and people who earn more than the current Medicaid eligibility, and that obviously varies by state, but for adults, it tends to be very low. In some states, it can be 15 or 20 percent of poverty.

10:18:08

ROVNERFor children, they're already covered by federal law at 100 percent of poverty, but for adults it can be very low. You're not permitted to get subsidies in the exchange unless you have 100 percent of poverty -- unless your income is up to 100 percent of poverty. So there could be an odd situation wherein some of the poorest adults wouldn't be eligible for anything, neither Medicaid nor the exchange subsidies.

10:18:31

REHMJulie Rovner of NPR. Short break here. We'll be right back.

10:20:04

REHMAnd welcome back. In this hour, answers to your questions about the Affordable Care Act from Julie Rovner, health policy correspondent for NPR, Susan Dentzer, editor-in-chief of Health Affairs and on-air analyst for the PBS "NewsHour." Mary Agnes Carey, she is senior correspondent for Kaiser Health News, Ceci Connolly, managing director and leader of PwC's Health Research Institute, co-author of "Landmark: The Inside Story of America's New Health Care Law and What It Means for Us All."

10:20:49

REHMHere's an email -- let's see -- from Sandra, who says, "I'm already finding it difficult to find a doctor that I want who accepts Medicare. What impact will the law change have on the number of doctors willing to accept Medicare? I note a recent bone scan I had cost $698. Medicare paid $67.53. How can the health care system survive with these low reimbursements?" Mary Agnes.

10:21:29

CAREYWell, this issue of physicians taking Medicare in an ongoing sort of pressure point on Capitol Hill. There's a Medicare physician payment fix they have to routinely and continuously pass so Medicare physicians don't get their payments cut. In the health law, there'll be more money and more slots for training of physicians and nurse practitioners and physician's assistants to take the crush of these millions of people Ceci's is talking about who are going to have coverage.

10:21:56

CAREYBut whether or not a physician -- most physicians -- many physicians take Medicare. The Medicare Payment Advisory Commission, this advisory body to Congress, talks about high access rates to Medicare. But you hear this a lot from people anecdotally talking about the difficulties they have. I think it's an ongoing pressure with new folks coming in the system and also the millions of baby boomers coming into Medicare.

10:22:18

REHMSusan.

10:22:19

DENTZERThis is a good time for us to talk about something else going on under the Affordable Care Act, which is an effort to really restructure the way we deliver and pay for health care in the U.S. We don't do that very efficiently, and let's point out, paying $695 for a bone scan, which basically is waving a wand over you, is not so much a question of Medicare underpaying. It's that the system is costly beyond all reason. Probably, Medicare is paying a totally appropriate amount for that. So we have to come up with ways.

10:22:52

DENTZERPeople use the phrase the triple aim. We have three things we need to aim for: We have to have better health in this country, we've got to have better health care, and it's got to cost less. So as we try to reconfigure the system, what we will see and what people like the caller will see is new arrangements where you might join something called an accountable care organization under Medicare, where a whole organization is in charge of your health. So you may have much better access to primary care, your day-to-day care.

10:23:24

DENTZERYou might be seeing a nurse practitioner before you see a doctor. You might be getting regular calls from the office saying come in and get these tests that you deserve. We're going to move into some very different systems over the next few years. And particularly for people who are on Medicare Advantage, which is the sort of program that is set up to do this already, there are going to be lots of new opportunities to join systems that will have this kind of better access.

10:23:51

REHMAll right. To San Jose, Calif., good morning, Afeth. (sp?) You're on the air.

10:23:57

AFETHGood morning, Diane. Thank you very much for taking my call. First, I'd like to say I listen to you every day, and I love your show. I drive a truck, so I listen to you while I'm driving across the country. My question is how does my -- the Obamacare -- the House -- is going to affect me as far as -- my job offers me an insurance already, but I don't want it. So if I decline that and then if I want to go get my own, if I want to buy, how much is it going to cost me?

10:24:27

DENTZERWell, it's going to depend on lots of things, not the least of which is where you live. It sounds like your employer is now offering you coverage, but you're turning it down. One issue will be, will your employer give you some money instead? If so, you could go to the health insurance exchange that is set up in the state where you live and buy coverage that way. Basically, it would mean you would go online, just like you'd go online to shop for an airfare, whatever. You'd pick an insurance plan that you like.

10:24:57

DENTZERIf your employer again is offering you some contribution towards that, you would buy it with that sum plus whatever else you had to pay out of pocket, and you'd further have a choice of how generous the plans would be. Their plans are going to be labeled according to medals. You're going to be able to get either bronze plan or the silver plan or the platinum plan or the gold plan. And those will cover different levels of cost sharing, deductibles and so forth. So you'll -- you would have a lot of choice. The key issue, though, is, is your employer going to help support that coverage for you?

10:25:32

REHMCeci.

10:25:33

CONNOLLYDiane, this question ties in with the individual mandate, which we now know in 2014, it's less of an option to say I don't want health insurance. You could face a penalty if you don't sign up for some. One thing that we saw in Massachusetts -- and it's just one place and one snapshot, of course -- not every state is exactly the same. But in Massachusetts, once that individual mandate went in place, we saw more people going back to their employer and saying, you know what, now, I think I would like to sign up for the health coverage that you're offering me.

10:26:06

CONNOLLYAnd there might even be more conversation between employers and employees about what that coverage should look like, really the marketplace getting creative.

10:26:15

REHMJulie.

10:26:16

ROVNERI should point out that not everybody is going to have the option to decline their employer's insurance and go in to the exchange. That was something that they really wanted to make sure wouldn't happen. They didn't want people to say, I don't want to -- I don't like what my employer is offering. I'd rather go shop on the exchange 'cause they're worried that they would have a flood of people moving to exchanges.

10:26:34

REHMI see. OK.

10:26:36

CAREYBut we should further say that many -- all states that set up an exchange also have to set up a small business health insurance exchange. So if his employer is a small business that he might be able to, again, buy coverage through the exchange, it depends on what the employer decides to do.

10:26:53

REHMAll right. To San Antonio, Texas, and a small business owner. Good morning, Charlie.

10:27:01

CHARLIEGood morning.

10:27:02

REHMGo right ahead, sir.

10:27:04

CHARLIEWell, as mentioned, I'm a small business owner. I do have over 15 employees. I'm subject to the terms of the employer mandate. But I've seen various discussions as to whether an employer offers insurance versus provides insurance. Those are not synonyms. So if my employees do not elect 75 percent participation level, the insurance company won't insure me. So in that case then, am I fulfilling my obligation to offer or provide, or am I subject to a penalty because fewer than 75 percent of my people elected insurance?

10:27:40

REHMWho can answer that?

10:27:41

CAREYWell, the first thing to say is that the administration, even as we speak, is trying to work out some changes in the employer penalty provision because of the way it was drafted. It was not drafted artfully and probably would've been fixed if there had ever been a conference committee on the bills, which there never was. So the most important thing to say is what -- it's going change. They are going to make some changes.

10:28:10

CAREYThat said, I think that the issue is with the 75 percent coverage, I think, is going to be one of the issues that is affected here because if people have the option of going to the exchange, it's a whole different ballgame then in terms of working with your insurance company.

10:28:31

CAREYI don't necessarily need to engage in a dialogue here, but to find out whether you're a self-insured, are you actually self-insuring and just getting an insurer to administer your benefits, or are you actually buying insurance? It sounds like the latter, that you're actually buying coverage. But there -- in the new world, with exchanges, this is going to change rather remarkably.

10:28:54

REHMAll right. Here's an email from Tyler, who says, "I cannot afford insurance right now. I make about $22,000 a year. What exactly is the penalty or tax for not buying insurance? I don't see how this new law helps people who wanted insurance but couldn't afford it anyway." And Tyler lives in Michigan. Mary Agnes.

10:29:25

CAREYThere are exemptions from the mandate and the penalty based on affordability. So there may be some help there. And also, this particular person may qualify for a subsidy.

10:29:35

REHMRight.

10:29:36

CAREYSo you can't afford it now, but in 2014, on a sliding scale, there'll be money, and to Susan's point, exchanges where you can go, so he may be able to afford it at that point.

10:29:44

REHMAll right. To Englewood, Fla., good morning, Lorraine.

10:29:48

LORRAINEOh, good morning. How are you, Diane?

10:29:49

REHMFine. Thank you.

10:29:51

LORRAINEOK. I wanted to ask a question. How will illegal immigrants fare with the new affordable health care plan?

10:29:58

REHMJulie?

10:29:59

ROVNERThey're not covered. This was a big fight, and it's -- of the number of people who will remain uninsured after this is all implemented, people who are not here legally will be the vast majority of them. There is -- there's $11 billion put into the law to beef up community health centers so that people who remain uninsured will have a place to go to get care. But hospitals are particularly worried about this because the -- people who are not here legally, still won't have insurance, are still going to end up in emergency rooms. This is a major concern.

10:30:33

REHMAll right.

10:30:33

ROVNERAnd they will not be eligible to go to the exchanges.

10:30:35

REHMAnd to Southern Pines, N.C. Hi there, Dan.

10:30:40

DANHi. Good morning, ladies.

10:30:41

REHMGood morning.

10:30:41

DANMy question is in regards to military health coverage. I'm currently active duty in the military, and it's relatively low. We pay a lot less in health care costs than the average American. But at the same time, our service is relatively shoddy at best. I've sat down in a chair and accidentally gotten a root canal instead of a cavity fill, and I've had my entire shot record get lost and had to get my whole panel of shots again.

10:31:10

DANSo my question is, does this law provide -- what sort of coverage is provided? If my rates do increase, will I have the opportunity to go out and seek out health care from a different provider, choose my provider, anything like that?

10:31:26

REHMJulie.

10:31:27

ROVNERThis law very much left the military system and TRICARE, which is the system for the -- most of the military dependents, alone. And, in fact, I remember when the provision to allow children up to age 26 to stay on their parents' plans went into effect, it did not cover TRICARE initially, and the military -- people on military plans went nuts because it didn't.

10:31:51

ROVNERAnd then Congress had to go back and very quickly remedy that because originally they said, no, don't touch the military health care system. We don't want to be part of this until suddenly a really popular benefit went in, and they said, hey, how come we weren't part of this?

10:32:03

REHMSo if, for the most part, Dan stays within the military framework, then that's it?

10:32:11

ROVNERYes.

10:32:11

DENTZERBut...

10:32:11

REHMThat answers it, Dan.

10:32:13

DENTZERBut as with all of this, we have to see how things evolve over time because you could imagine a day when -- and the military is under as much cost pressure with provision of health care as anybody else. You could imagine a day where the military will also might move to allowing -- supporting people to buy coverage through exchanges.

10:32:32

REHMHere's a quick question from Debbie: "When will the no co-pay for preventive care kick in? I was charged earlier this year and asked and was told it was not in effect." Mary Agnes.

10:32:50

CAREYIt is in effect for many plans. But I believe if the health plan is one of these grandfathered plans -- it's a small select group of plans that are grandfathered until 2014 -- they would be allowed to say, you do have to have a co-payer deductible on preventive care.

10:33:05

CONNOLLYBut, you know, Diane, one of the interesting things that we're seeing from a number of the health insurance companies now is they're starting to move ahead with some of the exchanges sooner rather than later. They either think that it's good medicine to get people preventive care, primary care, wellness.

10:33:21

REHMMore profitable?

10:33:22

CONNOLLYOr it could be profitable. Or they may be thinking about their image. So for a whole variety of reasons, many of them are jumping out ahead.

10:33:32

REHMCeci Connolly. And you're listening to "The Diane Rehm Show." Let's go to Boone, N.C. Good morning. You're on the air, Doug.

10:33:43

DOUGGood morning. Thanks, Diane...

10:33:45

REHMSurely.

10:33:45

DOUG...and I appreciate your taking my call.

10:33:47

REHMSurely.

10:33:48

DOUGI'm 59 years old this August. My insurance started out. I buy my own insurance, private insurance through a nice big company. I started out at 50 with this policy. It was at about $4,500 a year. Three years...

10:34:08

10:34:20

KIPGood morning. Thank you for taking my call.

10:34:23

REHMSurely.

10:34:23

KIPI work in road construction, and so my year is not as long as the average work here, and also a good part of that includes unemployment compensations. My annual income bounces all over the place. How is it going to adjust for that on someone like me?

10:34:42

REHMJulie?

10:34:43

ROVNERI believe you have to -- you end up reporting on your income tax form. So it's -- although it's going to be tricky to figure out what your subsidy would be monthly.

10:34:54

CONNOLLYThere are also some ideas developing in some states right now, Kip, where states are considering, for instance, Medicaid eligibility and exchange eligibility if they want to look at that quarterly. We did some research and determined that there will be 38 percent of the people in Medicaid on any given year will move in and out of Medicaid. It's called, in the insurance world, churn. And there's going to be a number of people who may move back and forth. Now, they're trying to make that as seamless as possible, but it will be a challenge.

10:35:28

DENTZERBut the bottom line, though, as Julie said, if you -- you will report your income each year, and the subsidy will be related to what your income is. So the subsidy that you would get for the first year would be related to the income you have reported in the prior year. So they'll make -- the government will make some estimation of what your income is likely to be and calculate your subsidy to buy coverage in the exchange accordingly.

10:35:55

REHMKip, thanks for calling. Here's an email from Bob, who's listening on WFAE in Charlotte, N.C., who says, "My daughter-in-law is a nurse, employed by a Novant hospital. She says their CEO called a meeting and, among other things, warned them that the Affordable Care Act could cost them to lose their jobs because it would become so expensive for the hospital to provide health care. Is it possible that this is true?" Julie Rovner.

10:36:36

ROVNERI'm not sure exactly why or how. So I would -- I think I would kind of need to know more.

10:36:44

DENTZERParticularly -- the hospital is already providing coverage. Coverage is getting more expensive anyway. If the law had never been passed, health insurance premiums -- you know, health insurance premiums more than doubled over the past decade, so insurance premiums are going up regardless. There is a lot of hope that some of the pressures going on in -- with respect to the payment and delivery reform that I was talking about earlier, are actually going to hold down the cost of coverage.

10:37:11

DENTZERWe will have to see how that plays out over time. But there's no reason per se, I don't think, that the hospital's coverage is going to get more expensive because of the Affordable Care Act.

10:37:21

REHMMary Agnes.

10:37:22

CAREYThey're going to have a lot of business. You're going to get all these people covered on these subsidies, exchanges, on Medicaid. You got the baby boomers. They're going to be busy.

10:37:29

10:40:04

REHMAnd as we come back to the brain trust of health care and the Affordable Health Care Act, I have with me Julie Rovner of NPR, Susan Dentzer of Health Affairs and PBS, Mary Agnes Kerry of Kaiser Health News, Ceci Connolly of PwC's Health Research Institute. Here's an email, "I've heard many large companies, including McDonald's, have been given waivers. Discuss what those waivers entail and why they are given. What do they mean for employees of those companies?" Julie.

10:40:50

ROVNERYes, this has been very controversial. And, yes, McDonald's is among the companies that got these waivers. They are waivers for plans that have insurance that offers less than the annual limit for care. Right now, there's an -- a lot of these plans have what are called mini meds, and McDonald's in particular has been very highly criticized because they have these very inexpensive plans that don't cover very much.

10:41:12

ROVNERThey'll cover 10 or $20,000 worth of care, and they -- you know, they may only cost $50 a month 'cause you don't make that much when you work at McDonald's. But again, if you get very sick, it's not very good coverage. On the other hand, the administration was faced with this dilemma of saying -- McDonald's saying, OK, you're going to outlaw these plans, and we're not going to offer anything. So it's either give them a waiver and let them continue to offer these very substandard plans or have them offer nothing until 2014.

10:41:38

REHMSo how long does this last?

10:41:40

ROVNERThey only go until -- well, they -- a lot of them they gave a one-year waiver, but I think the implication is that they're probably going to end up going until 2014, that there'll be bridge until people can get on the exchanges.

10:41:49

REHMOK. All right. To St. Louis, Mo. Michelle, good morning.

10:41:57

MICHELLE...Diane.

10:41:58

REHMSure. Go right ahead.

10:42:00

MICHELLEOK. So my situation is is that I -- my children are on Medicaid. I have three children on Medicaid. Obviously, I'm -- I fit the criteria. My finances isn't enough. Even though my job offers the insurance, it's way more expensive than I could afford and then afford to live. So my daughter will be going to school in August. However, Missouri will cut her off of her medical insurance at 19. She's 18 now. At 19, how will I insure her? How will I be able to insure her? Because just because she turns 19 doesn't mean that I'm going to be able to financially do it. My finances haven't changed.

10:42:45

REHMCeci.

10:42:46

CONNOLLYWell, that's going to be a tricky one at least for another year-and-a-half or so, I think. I mean, again, come 2014, we anticipate there'll be possibilities of shopping on the exchange, probably with those subsidies or those discounts for a number of working-class Americans. It's possible that Missouri may go ahead and do the Medicaid expansion, which would then mean that Michelle herself could get coverage through Medicaid depending on that salary level so...

10:43:18

CAREYAnd the 19-year-old daughter.

10:43:19

CONNOLLYAnd the 19-year-old daughter as well.

10:43:19

REHMAnd the 19-year-old.

10:43:21

CONNOLLYBut it could be a tough year-and-a-half. I don't -- unless -- I'm trying to think if there would be something available right now.

10:43:29

ROVNERIf she applied to -- the 19-year-old applied for health insurance and were turned down theoretically because she had a pre-existing condition, then you could look at the high-risk pool facet of the law. Now the problem there is going to be the affordability of it.

10:43:40

REHMOf course.

10:43:41

ROVNERSo there are state high-risk pools. There are also some separate high-risk pools that are government setup as part of the health law, but that would be the difficulty. Could you afford it even at a reduced price which some of the federal pools are?

10:43:52

REHMSo she's got to stay very alert to what's happening to the changes and to what's available in Missouri. Let's go to Silver Lake, Ohio. Good morning, Mark.

10:44:07

MARKGood morning. My question regards Chief Justice Roberts explaining that he's supported the individual mandate in the context of it being a tax. And I'm wondering if your guests thinks that this might be window -- a possible avenue to getting rid of this 800-pound gorilla in the room, the health insurance industry, and doing what every other industrialized nation has done and gone to a single-payer system.

10:44:36

REHMMary Agnes.

10:44:38

CAREYI don't think it will go -- it will get us to go to a single-payer system. I mean, even if you go back to 2009 way before the political struggle over the health care law, that didn't seem to be the political will to do that. But to his point about it now being reframed by the Supreme Court as a tax under Congress' ability to tax, that's going to be a political point for Republicans. We're going to say not only does this law have all these other taxes on the health insurance sector or the pharmaceutical sector or the medical device sector, but now you, America, are going to get your taxes raised if you don't get health insurance.

10:45:10

CAREYNow, that's probably a very small amount of people that are going to have to pay that penalty, but this was going to be a rallying cry for Republicans, for the Republican base in the election.

10:45:18

CONNOLLYThe great irony of the Supreme Court decision is that all the justices agreed during the oral arguments that if Congress had passed a single-payer plan, it would have been completely constitutional. There would have been no question that the government had the ability under the taxing power again necessary and proper.

10:45:38

CONNOLLYAll of those powers accorded the government and the Constitution the government could have carried out. It was only because this plan basically reached into the private insurance market and also had this individual mandate that there was any question at all about the constitutionality of it.

10:45:55

REHMBut there was no chance of a single-payer plan getting through that Congress.

10:46:02

CONNOLLYExactly right. And that is the ultimate irony.

10:46:04

REHMAll right. Let's go back now to Doug in Boone, N.C. Glad you got back on, Doug.

10:46:12

DOUGThank you, ladies. My question and statement a few moments ago was when I turned 50 years old, my policy that I bought was around $4,500. Three years ago, it went up to $10,000. Last year, it was $12,000. This year in May, for one year's coverage, $16,253.

10:46:37

REHMDid you have a pre-existing condition, Doug?

10:46:41

DOUGI do have a couple small things, but I mean, where does this top out at? Is there a cap on this? I feel that the insurance companies are raising these premiums so high that when there is a cap, then I won't be able to afford it anymore.

10:46:56

REHMYeah.

10:46:57

DOUGAnd then I'll be indigent just trying to get, you know, the cheapest insurance, and you don't get the best coverage.

10:47:05

REHMSo tell me how you're employed, Doug.

10:47:09

DOUGI'm self-employed.

10:47:09

10:47:16

ROVNERWell, the good news for him, which is kind of the bad news for younger people, is that they are narrowing what's called the age bans. Right now, you can charge older people more. I think that's probably his pre-existing condition is called the good news. He's getting older. The bad news, he's getting older. As your age goes up, so does -- so do your rate.

10:47:33

ROVNERAnd right now, they're only going to be allowed to charge older people three times more than younger people, so he's -- therefore, being older will not be such a big penalty. Problem is that if you're younger, you're going to have to pay more to subsidize those older people, so...

10:47:46

REHMAnd speaking of penalties, here's a tweet, saying, "I heard insurance companies will create plans that cost the same as the penalties. Is that true, Ceci?

10:48:01

CONNOLLYWell, yet to be determined, but we certainly know that the insurance companies are going to get much more creative about the plans that they sell on those exchanges because they recognized it's a very different consumer than the one that they've been selling to. You stop and think for a minute, Diane, about 56 percent of Americans now get their health care through an employer, mostly large employers in this country. And what happens is your employer negotiates with an insurer, and they come up with a choice or two for you of plans.

10:48:32

CONNOLLYOut on those exchanges are going to be people who are shopping one by one. We call it retail shopping, just like you go when you buy anything on Amazon or eBay online. And so these insurance companies have to get much savvier about designing products for this very different customer base, and they're going to be very cost-conscious.

10:48:54

REHMIt sounds to me, though, as though those who would like to be insured are going to have to get very savvy about making those choices because there are going to be so many choices out there.

10:49:09

CONNOLLYThat's absolutely right. But I think back to the experience with the Medicare Part D prescription drug benefit. And, you know, somebody could probably go and find the tape of me saying, gosh, it's going to be hard for a lot of these retirees to make this choice. It's going to be complicated. They're going to have to get on the Internet. And it's really gone pretty well, I have to say. The Medicare beneficiaries are pretty satisfied with it. They're making their choices. They're getting coverage. So maybe we need to give the consumers a little credit.

10:49:39

REHMAll right. To Baltimore, Md., good morning, Katherine.

10:49:43

KATHERINEGood morning. I'm calling about the no co-pay principle for the contraceptive services, and I'm wondering...

10:49:56

REHMOh, dear. Our telephones -- I think what she wanted to know, will the Affordable Care Act offer contraceptives with no co-pay, and will that be regardless of income? Julie.

10:50:16

ROVNEROh, that is set to take effect this August 1. If the religious organizations will be able to get a year's extension on that, there are several lawsuits that have now been filed. Some are trying to get that delayed, so that is still a source of controversy. But, yes, that is part of the law. That is one of the rules that has been put into effect as part of the law, and it is about to go into effect.

10:50:42

REHMOK. But help me understand this. You normally, I think, don't you go to the drug store for condoms?

10:50:52

ROVNEROh, no. This is only for prescription contraceptives.

10:50:55

REHMOnly for prescription.

10:50:56

ROVNEROnly for prescription contraceptives.

10:50:57

REHMOK. All right. Let's go to Giovanni in Tampa, Fla. Good morning. Giovanni, are you there? Not there. Let's try Bristol, Va. Good morning, Randy. I'm afraid our phones are not working. Here is an email from Stephanie in Michigan, who says, "My husband has declined the insurance through his company. They compensate him as a result, and he has opted to have insurance through my company's insurance. Will we be affected at all?" Julie.

10:51:42

ROVNERNo. Many, many people do that where both members of a couple work and they choose which spouse's insurance to be on. That's very common, and that's going to be fine under this.

10:51:54

CAREYAll you'll have to do is show on your tax return that you both have coverage.

10:51:58

REHMOK. Here is another from Boston who says, "My current employer offers a health care plan. He does not provide it but offers it. I am a temp. I may be employed for two to six months, but when the project ends, I'm out. I don't have funds to buy the COBRA upfront. I might be back working for my current employer when they get another project in a week or two or six, or I might be working for someone else, or I might be looking for work for a couple of months. What will the Affordable Care Act do to affect this?" Ceci.

10:52:42

CONNOLLYDiane, this sounds like exactly the kind of person who will be shopping on the exchange. Now, the one thing that's a little bit curious is already being in Boston, there is now an exchange in Massachusetts, and there are some purchasing subsidies available. So that individual might want to do some checking into the Commonwealth Connector, which is the name of it up there. I mean, there are probably already some opportunities in that state. But in the other states...

10:53:08

ROVNERAnd there is a mandate. That's what she says.

10:53:09

CONNOLLYAnd there is a mandate.

10:53:10

DENTZERIt's a requirement.

10:53:11

CONNOLLYYes. And that does get recorded on their taxes. So Massachusetts is a little bit further ahead in some respects, but it sounds like a good candidate for exchange.

10:53:21

REHMAnd you're listening to "The Diane Rehm Show." You know, sounds to me as though this is pretty complicated. How much will the government push for transparency in all of this to try to make it easier for consumers to navigate? Susan Dentzer.

10:53:47

DENTZERWell, speaking of the word navigate, inherent in the law is a requirement that all of the states, as they set up their exchanges, also have navigators. There are going to be people employed to help people through this process. In addition, states have the ability to decide whether they want brokers to be able to participate, insurance brokers. And probably many states will go that direction as well.

10:54:12

DENTZERSo that will mean that if you're a small business trying to figure out what to do through the SHOP exchange, the Small Business Health Option exchange, you'll have -- be able to have the assistance of either a navigator or a broker. If you're an individual, you'll be able to have the assistance of a navigator. So the states again are going to have to set this up, but in theory, everybody will have some assistance to help navigate their way through this.

10:54:38

REHMMary Agnes.

10:54:39

CAREYInsurers are also going to have to present sort of plain English explanations of what they cover and what they don't. If you try to go through a plan booklet now, it can be a little daunting. They're going to have to simplify that. It's going to the regulatory process and insurers are pushing back a bit. But ultimately the thought is, not only will you have the assistance Susan is talking about, but the insurers themselves can summarize cleanly and succinctly what the plan covers and what it doesn't.

10:55:00

REHMCeci.

10:55:01

CONNOLLYWell, Diane, the other thing is, don't forget the marketplace. I mean, the change that is going on out there across the country in the health care industry is amazing. I mean, if you stop and think about how banking has changed in this country -- remember when we used to take our paycheck on Friday that the teller would...

10:55:16

REHMYou bet.

10:55:17

CONNOLLY...deposit it and get our spending money for the weekend?

10:55:18

REHMSure.

10:55:19

CONNOLLYWhen was the last time any of us set foot in a bank, right? I mean, our bill pay is online, et cetera, et cetera. That transformation that happened so rapidly is the kind of thing that's getting started in the health care world.

10:55:31

REHMAnd the question for everyone is, is this truly going to bring down health care cost? And that's what everybody is worried about. Julie.

10:55:43

ROVNERYou know, there is -- the big wrap on this bill is that it didn't do enough to bring down health care costs, and it's probably true. On the other hand, nobody really knows how to bring down health care costs. So there is certainly the hope that, you know, everything that everybody knew how to do or thought might work or hoped might work is in this law. Whether it works remains to be seen.

10:56:02

REHMSusan.

10:56:02

DENTZERAnd the things that we know would work, people don't want. I mean, people do not want to be -- have their access to doctors restricted. People do not want to have benefits cut. So it is really a quandary how we figure out a way to have health care cost less in a way that people will accept.

10:56:21

REHMMary Agnes.

10:56:22

CAREYI think it's -- to Julie's point, it's highly unclear. The academics, everything that they've thought will work, could work is in this law. But I think it's going to take decades to know whether this reduces health care cost or not.

10:56:34

REHMCeci.

10:56:34

CONNOLLYHealth care cost will never go down in this country, but the hope is that we can slow the crazy rate of growth. And that has been happening the last couple years in part because of the recession, in part because of some behavior change. Patients starting to become a little bit wiser about the choices they make, whether or not you necessarily need a full body scan or getting rid of duplication in the system, that kind of thing.

10:57:01

REHMWell, the star team, I want to thank you all so much for being here. And I hope you'll come back as this plan becomes implemented little by little. Ceci Connolly, Mary Agnes Carey, Susan Dentzer, Julie Rovner, thank you again. And thanks for listening. I'm Diane Rehm.

Monday, Mar 30 2015Airstrikes led by Saudi Arabia in Yemen against anti-government forces are raising fears the conflict may spread. A look at how regional powers are aligning and debate over the role of the U.S.

Friday, Mar 27 2015An update on the plane crash in the French Alps. Saudi Arabia launches air strikes against Yemen rebel bases. And President Barack Obama slows U.S. troop withdrawal from Afghanistan. A panel of journalists joins Diane for analysis of the week's top international news stories.

Friday, Mar 27 2015The House passes a budget with no Democratic support. Republican Senator Ted Cruz enters the 2016 presidential race. And the Army charges Sergeant Bowe Bergdahl with desertion. A panel of journalists joins Diane for analysis of the week's top national news stories.